Care Review Clinician I

Job Description:

Work Location (i.e., onsite or remote based): Remote based but candidates can be located anywhere in the US but must be licensed in NY State. Will now accept RN's!

Job Description:

All UM standard/ expedited Inpatient, Outpatient and Custodial Care clinical reviews for MLTC members.

Must Have Skills:

Must have experience in UM, experience with Turnaround Timeframes, good with computer systems and be able to learn a new system, have done clinical reviews and processed denials and partial denial determinations, know MCG and can use it, case presentation for medical reviews, know Medicaid/ Medicare guidelines.

Bi-lingual Spanish, Bengali or Mandarin. - PREFERRED! NOT Mandatory.

Please ensure that candidates have experience with actually reviewing for Medicaid/ MLTC members not Medicare or IP reviews as those are very different with a different workflow and process.

Candidates must be aware that this is a fast-paced environment with a Turn around Timeframe of 3 business days on average for our std requests as we do not get many urgent/expedited requests.

Day to Day Responsibilities:

All UM standard Inpatient, Outpatient and Custodial Care processes and workflows for any requests, verbal notifications for denials/partial denials to both member and provider, participation in IDTs, personal queue management and clinical reviews.

Required Years of Experience:

At least 1-2 years experience in UM.

Required Licensure / Education:

Licensure required is a NY State License Practical Nurse or Registered Nurse -LPN NY & NY RN

Be sure to include the type of authorizations that were performed.

Attendance is VERY key- please ensure that candidates do not have any Pre planned vacations during the month of October, November or December. we have 11,000 members who will be needing reassessments then and will have an uptick in auths/requests as well as the holidays right after in Nov and Dec.

Any pre planned vacations must be disclosed during the interview and submission.

Summary:

Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing *** members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Client Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Essential Functions: Provides concurrent review and prior authorizations (as needed) according to Client policy for Client members as part of the Utilization Management team. Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. Participates in interdepartmental integration and collaboration to enhance the continuity of care for Client members including Behavioral Health and Long Term Care. Maintains department productivity and quality measures. Attends regular staff meetings. Assists with mentoring of new team members. Completes assigned work plan objectives and projects on a timely basis. Maintains professional relationships with provider community and internal and external customers. Conducts self in a professional manner at all times. Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct. Consults with and refers cases to Client medical directors regularly, as necessary. Complies with required workplace safety standards.

Knowledge/Skills/Abilities:

Demonstrated ability to communicate, problem solve, and work effectively with people.

Excellent organizational skill with the ability to manage multiple priorities. Work independently and handle multiple projects simultaneously. Knowledge of applicable state, and federal regulations. In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.

Experience with NCQA.

Ability to take initiative and see tasks to completion. Computer Literate (Microsoft Office Products).

Excellent verbal and written communication skills. Ability to abide by Clients policies. Ability to maintain attendance to support required quality and quantity of work. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.

Required Education:

Completion of an accredited Registered Nursing program. (a combination of experience and education will be considered in lieu of Registered Nursing degree).

Required Experience: Minimum 0-2 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management.

Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.